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Revista Pan-Amazônica de Saúde

versão impressa ISSN 2176-6215versão On-line ISSN 2176-6223

Rev Pan-Amaz Saude vol.11  Ananindeua  2020  Epub 21-Maio-2020 


Access to health services for riverside residents in a municipality in Amazonas State, Brazil

Ananias Facundes Guimarães (orcid: 0000-0002-5353-0262)1  , Victor Linec Maciel Barbosa (orcid: 0000-0003-2473-4829)1  , Mariana Paula da Silva (orcid: 0000-0003-1946-6110)1  , Jéssica Karoline Alves Portugal (orcid: 0000-0002-0142-2315)1  , Marcelo Henrique da Silva Reis1  , Abel Santiago Muri Gama (orcid: 0000-0001-5089-6990)1 

1 Universidade Federal do Amazonas, Instituto de Saúde e Biotecnologia, Coari, Amazonas, Brasil



To describe the characteristics of access to health services for riverside dwellers in the Municipality of Coari, Amazonas State, Brazil.


Descriptive, cross-sectional, population-based study was conducted with riverside dwellers in the rural area of Coari, from April to July 2015. The interviews were conducted using a previously prepared questionnaire. Socioeconomic, demographic and access to health services variables were used. The probabilistic sample by clusters was composed of 492 subjects.


More than half (54.9%) of the riverside inhabitants used small wooden boats to access health services, sailing the average of 60 km and of 4.2 h travel time. The health service most sought by those populations was hospital (65.0%), followed by Basic Health Unit (26.6%), and pharmacies (5.4%). About one in four riverside dwellers (22.2%) stated that they tried unsuccessfully to book a medical appointment, with the main reasons being there were no appointments available (57.8%), the lack of professionals to assist them (28.4%), and the delay to get appointments (13.8%).


The access to health services for riverside dwellers is limited, especially by geographical barriers. It is necessary to articulate strategies that promote access to health services, enabling the continuity of health care to this population.

Keywords: Rural Population; Vulnerable Populations; Universal Access to Health Services


The Brazilian Amazon has an approximate surface area of 5,217,423 km², corresponding to about 61% of the Brazilian territory, among which about a third (1.6 million km²) belongs to the largest state in Brazil, Amazonas. Inversely proportional to the extensive territorial area, the State has the second-lowest demographic density in the country (2.2 inhabitants/km²)1.

The demographic dispersion and the vast territory, bathed by extensive hydrographic basins and covered by the largest tropical forest on the planet, impose severe inequalities in access to health care and other social distortions concerning other Brazilian regions2.

The riverside populations of the Amazon are descendants of indigenous peoples mixed with northeasterners and other migrants and live on the banks of rivers and lakes3. These inhabitants survive from fishing, hunting, family farming, and subsidies from the federal government's social programs. Their communities lack basic resources, such as basic sanitation and electricity, and depend on urban areas to purchase consumer goods and health care. Commute to urban areas is by the river, using small boats, on trips that can last from a few minutes to days of navigation2. Along with the adverse conditions in the region, riverside dwellers are exposed to infectious diseases (malaria, parasitic diseases, Chagas disease)4 associated with typical morbidities of large urban centers, such as hypertension and diabetes5.

Although the Federal Constitution of 1988 guarantees the right to universal and equal access to health for all Brazilians6, there is evidence that access has been a challenge for users of the Unified Health System (Sistema Único de Saúde - SUS).

A study carried out at the national level and with data from the National Household Sample Survey (Pesquisa Nacional por Amostra de Domicílios - PNAD), excluding the rural population of the states of the North Region, pointed out that the main reason for not obtaining health care was not getting a vacancy or there were no doctors available7.

In the metropolitan region of Belo Horizonte, health professionals pointed out some factors that hinder access to health by the population: the distance from the user's residence to the Basic Health Unit (Unidade Básica de Saúde - UBS), the deficiency of public transport in the city, and the impossibility of paying transport due to economic difficulties8.

In the North Region, an investigation carried out with fishers along the Machado do Ji-Paraná River, in Rondônia State, pointed out that, when seeking a health service, the most significant problems they faced were the lack of specialist doctors, the delay in making appointments and specific exams and the lack of medication in the UBS9.

The access limitations to health services make up a multifactorial, complex, and subjective context10, which may affect different aspects of the way of life of these populations. In this sense, this study aimed to describe the characteristics of access to health services by riverside dwellers in the municipality of Coari, Amazonas, Brazil.


This study is part of the research "Health, Medicines and Self-medication in Ribeirinhos do Amazonas" (Saúde, Medicamentos e Automedicação em Ribeirinhos do Amazonas - SAMARA).

This is a cross-sectional, population-based study conducted with riverside dwellers living in the rural area of Coari, carried out from April to July 2015.

Coari is located in the central region of the Amazonas State, in the middle channel of the Solimões River, 363 km away from Manaus. Access to the city is done by river (9 to 30 h of travel, depending on the vessel) or by air (1 h to Manaus). The estimated population in 20171, was 84,762 inhabitants. The territorial area of Coari is 57,970 km² and the demographic density is 1.3 inhabitants/km².

The primary health services in Coari are a medium-complexity hospital (105 beds), 12 UBS, a Tropical Medicine Institute, a Fluvial UBS, a hospital boat to cover all riverside communities, a Central Laboratory for Clinical Analysis, a Service of Emergency, a Health Surveillance Center, a Polyclinic, and a Psychosocial Care Center11.

The inhabitants of the rural area are distributed in communities scattered along the banks of the Solimões River, lakes and streams, in areas of dry land and floodplains.

The calculated sample consisted of 470 subjects, depending on the number of riverside communities covered by the Municipal Secretariat of Health of Coari (N = 135), to ensure the representativeness of the territorial research area and the number of adult inhabitants (N = 10,333). The technique of probability sampling by conglomerates was adopted. The details of the sample calculation can be seen in a previous publication2. Individuals aged 18 years or older who were in residence at the time of the questionnaire application were included.

This investigation collected socioeconomic, demographic, and access to health services information. Questionnaires were administered by previously trained interviewers from the Health and Biotechnology Institute of the Federal University of Amazonas. The riverside dwellers were approached in their homes and invited to participate in the study.

The variables analyzed were those of a demographic nature (gender, age, marital status, residents per household), socioeconomic (education attainment, monthly family income, labor activity), and access to health services (distance and time to access health services, search for health services in the last 30 days, transport commonly used for access, professional and service you seek in case of illness, attempt to schedule appointments and reason for not getting the appointment.

Data were entered using a data entry mask in the software SPSS (Statistical Package for Social Sciences) v22.0 for Windows. Qualitative variables were described by calculating absolute and relative frequencies, and, for quantitative variables, measures of central tendency were calculated.

Individuals who consented to participate in this study signed the Free and Informed Consent Form. For those who did not know how to sign, fingerprint pads were available to collect fingerprints.

The study was approved by the Research Ethics Committee of the University of São Paulo School of Nursing, under nº 33560914.0.0000.5392, on August 5, 2014.


A total of 492 riverside dwellers were interviewed, among which 53.0% were female, 88.6% were adults, 58.8% had low education level, and 63.2% had fishing and agriculture as an economic activity. Almost half of the riverside dwellers had a family income below the minimum wage (41.7%) (Table 1).

Table 1 - Distribution of research subjects according to socioeconomic and demographic variables, Coari, Amazonas State, Brazil, 2015 

Variables Riverside dwellers
N = 492 %
Male 231 47.0
Female 261 53.0
Age (years)
18 to 39 287 58.3
40 to 59 149 30.3
≥ 60 56 11.4
Yes 109 22.2
No 383 77.8
Education attainment (years)
Did not study 48 9.7
1 to 4 146 29.7
5 to 9 143 29.1
≥ 10 155 31.5
Marital status
Live alone 94 19.1
Live together 398 80.9
Work activity
Does not work 103 20.9
Agriculture and fishing 311 63.2
Civil servant* 59 12.0
Others 19 3.9
Monthly family income (MW)
< 1 205 41.7
1 to 2 195 39.6
> 2 92 18.7
Number of residents per household
1 to 5 246 50.0
≥ 6 246 50.0

* Civil servant: teacher, community health agent, and lunch lady; MW: minimum wage referring to April 2015 (BRL 788.00).

Among the interviewees, more than half (54.9%) of the riverside dwellers used small wooden boats powered by motors (sterndrive), to access health services, navigating an average of 60.4 km, with an average travel time of 4.2 h (Table 2).

Table 2 - Distribution of research subjects according to variables related to access to health services, municipality of Coari, Amazonas State, Brazil, 2015 

Variables Riverside dwellers
N = 492 %
Transport used to access health services
Sterndrive* 270 54.9
Recreio 169 34.4
Motorcycle 17 3.5
Rowing canoe 15 3.0
Community boat 11 2.2
Others 10 2.0
Distance from the community to the health service (km)
< 50 253 51.4
50 to 100 139 28.3
> 100 100 20.3
Average 60.4
Commute time from the community to the health service (hour)
< 1 54 11.0
1 to 4 251 51.0
> 4 187 38.0
Average 4.2

* Small motor-powered wooden vessel; Large vessel; Others: truck, on foot.

As for the type of professional most sought after in case of health problems, 42.7% said they sought doctors, followed by community health workers (36.2%) and pharmacists (5.3%). Regarding the most sought-after health services, 65.0% said they sought care directly at the city's hospital, followed by the UBS (26.6%) and pharmacies (5.5%). Among the interviewees, 22.2% of the riverside dwellers stated that they had already tried to make appointments without success and the most cited reasons were the lack of vacancies for scheduling (57.8%), lack of health professionals (28.4%), and long wait time for the appointments (13.8%) (Table 3).

Table 3 - Distribution of research subjects according to variables related to the access mode to health services, Coari, Amazonas State, Brazil, 2015 

Variables Riverside dwellers
N = 492 %
Whom to look for in case of illness
Doctor 210 42.7
Community health agent 178 36.2
Pharmacist 26 5.3
Nurse 23 4.7
Friend, neighbor or acquaintance 23 4.7
Nobody 16 3.2
Other* 16 3.2
Health facility you seek in case of illness
Coari Regional Hospital 320 65.0
Riverside UBS 131 26.6
Drugstore 27 5.5
Others 14 2.9
Attempt to schedule appointment unsuccessful
Yes 109 22.2
No 367 74.6
Never scheduled 16 3.2
Reason why the attempt failed (N = 109)
Lack of vacancies for scheduling 63 57.8
Lack of health professionals 31 28.4
Long wait time to schedule an appointment 15 13.8

* Prayer/Preacher: local healer; Coari Institute of Tropical Medicine; Private clinic.


The riverside population of Coari had low education and economic levels. The main activities carried out were agriculture and fishing, having rustic motor-powered boats (sterndrive) that travel long distances to access the urban area as the primary means of transport.

The low education level of riverside dwellers can directly affect how their health is managed. Furthermore, it portrays the need for specific actions that take into account the local reality and educational context.

Historically, rural populations worldwide are deprived of favorable conditions to improve the quality of life, which includes access to education, health, clean water, and sanitation. The 2015 Millennium Development Goals Report found that children are four times more likely to be out of school in rural populations in developing countries, and mortality rates are nearly twice as high compared to children of families with favorable economic conditions. Furthermore, only 56.0% of births are accompanied by specialized health professionals in these areas, while the percentage is 87.0% in urban areas. Another important aspect is access to drinking water sources (four times less) and access to sanitation (three times less) in rural areas compared to urban areas12.

Educational limitations also hinder economic development and, consequently, access to consumer goods (medicines, food, health plans), negatively impacting life expectancy. Furthermore, preventive health is hampered by the limitations of understanding the health-disease process, preventing morbidities, and promoting health13.

Educational limitations contribute to morbidity and mortality high rates from preventable parasitic diseases in the health context. Between 2001 and 2009, Brazil registered 13,449 deaths from diseases related to inadequate basic sanitation, corresponding to 1.31% of the total number of deaths in the period and about R$ 2.1 billion in SUS spending on medical consultations and hospital admissions14.

The Brazilian Amazon has several infectious diseases typical of the region and some other chronic ones arising from changes in eating habits in recent years5, providing a worrying environment concerning the control and prevention of these diseases. Many communities do not have electricity, limiting access to information provided by the internet, radio, and television. In addition, there is no basic sanitation, and to have drinking water is needed to use hypochlorite, not always available or with inadequate guidance as to how to use it, which can lead to a false impression of prevention2.

With regard to the low economic level of riverside dwellers, it is essential to discuss the impact of any health problem and the economic burden on the individual and their family. It is necessary to consider the distance to access health services (60 km on average), the duration of the trip (4 h on average), commuting costs (small wooden vessels require fuel), and, in cases of hospitalization, the costs of accommodation and food for companions, as riverside dwellers generally do not have a residence in the urban area. There is also the impact caused by the need to interrupt the activities of agriculture, fishing, among others, sometimes the only sources of income in the communities. The sum of these issues can affect the already limited income of riverside dwellers and the outcome of the health problem, forcing them to resort to resources available in the community itself15, which can aggravate the underlying problem in an attempt to solve or delay the search for the health service in the expectation of an improvement in the morbid condition.

Other studies carried out in riverside populations in the Amazon showed that geographic issues directly interfere with access to health services2,15,16. In other countries, such as Australia, safeguarding socio-political, geographic, and cultural differences, rural populations also suffer adverse consequences imposed by the same issues17, showing that geographic characteristics can limit the access to health services for these populations.

The Brazilian government directed some strategies to reduce the inequalities faced in access to health by vulnerable populations, including riverside populations in the Amazon. The Mais Médicos Program was created in 2013 (Provisional Measure nº 621/2013) to meet the needs of doctors in vulnerable regions of Brazil18. In that same year, the Northern Region of Brazil had the lowest ratio of physicians per 1,000 inhabitants (1.0 doctor/1,000 inhabitants), a situation that was aggravated in Amazonas State, especially in the inland (0.2 doctor/1,000 inhabitants), corresponding to a ratio 10 times lower when compared to the capital Manaus (2.0 doctors/1,000 inhabitants)16. Between 2013 and 2017, the Mais Médicos Program had 18,240 doctors (62.6% were Cuban doctors), distributed in 72.8% of Brazilian cities18. This program, notoriously, brought greater coverage of doctors in areas of difficult access and greater vulnerability; however, alone, cannot fill the gaps in health care for these populations19,20.

Another strategy that enabled advances in access to health by riverside populations was the implementation of the National Policy on Primary Care (Política Nacional de Atenção Básica - PNAB) (Ordinance MS/GM nº 2.488/2011 and Ordinance MS/GM nº 2.490/2011). According to the PNAB, municipalities in the Legal Amazon and Mato Grosso do Sul can choose between two organizational arrangements for Family Health Teams: the Riverside Family Health Teams (Equipes de Saúde da Família Ribeirinha - ESFR) and the Fluvial Family Health Teams (Equipes de Saúde da Família Fluviais - ESFF), which must be composed of at least one doctor, one nurse, one technician or nursing assistant and six to 12 community health agents21.

Although the strategies raised may have advanced in reducing inequalities in access to health care among riverside populations in Amazonas, in 2016, Constitutional Amendment nº. 95 was approved, which provides for a freeze on public spending for the next two decades, including health expenses22. In this context, considering the situation of vulnerability already imposed on riverside populations in the Amazon, such a measure may incur dramatic impacts with the reduction of investments and the increase in socioeconomic and access to health inequalities.

When analyzing the searches by type of service and health professional, the data indicate a preference for hospital service and medical care in case of illness among riverside dwellers. This situation may be related to the belief that medical professionals are the only ones capable of solving the population's health problems and the fact that the services offered by primary care are limited in their ability to resolve23. On the other hand, the limitations of access to health care and the possibility of complex morbid processes, possibly aggravated until reaching the health service, can lead to the need for specialized care in the hospital.

It should be considered that, as the UBS works during the day and there is a need to schedule appointments for emergency care or at another time, the only health service available would be the hospital. In addition, although riverside dwellers access the urban area of the municipality on a monthly basis2, the limited length of stay there and the time when the service is sought may not coincide with the operation of the UBS. Such findings warn of the need for service with free demand to contemplate the SUS premises of universality and comprehensive care24.

The community health agents were frequently sought out by riverside dwellers to resolve morbidities. As there are no health services in the riverside communities, these agents are the only professionals in these locations and act as intermediaries between the population and the network of health services. They are community residents and work in the Family Health Strategy, registering and accompanying families, through home visits, and also guide and develop activities to promote health in the community, preventing diseases and injuries21,25.

Pharmacies represented the third choice in case of health problems, and pharmacists. It is possible that these establishments replace, in some situations, the demand for health services, especially in cases of morbidities of "easy" resolution26, such as pain problems, very prevalent in riverside populations due to intense work activities. At this point, it is necessary to be concerned with the masking of illnesses, which can give rise to other, more severe illnesses. In addition, the search for pharmacies can encourage the consumption of medicines, increasing their medicine cabinet, promoting irrational use, and self-medication in riverside communities2.

About one in four riverside dwellers were not successful in scheduling appointments when they sought health services in the urban area of the municipality, mainly due to the lack of medical care forms or professionals for care. These data are in line with those of the PNAD, which pointed out such aspects as the main reasons for not getting health care by the Brazilian population7. It is worth noting that the aforementioned research excluded the rural population of the North Region, which indicates the need for studies that understand the access to health services in this region.

Among the limitations of the present study, it is considered that the capture of information about the time and distance of access to health services by riverside dwellers can vary significantly in relation to the time of the investigation. This study was conducted when the lakes and the river allowed navigation with ease (during floods), unlike what occurs in the dry periods (between August and November), which isolates some communities and substantially elevates the time taken to access health services.


Access to health services by riverside dwellers is achieved through small wooden boats, traveling long distances between communities to the health service. Riverside dwellers tend to seek the hospital more frequently, and it has been found that the difficulty in scheduling care is one of the main reasons that limit access to the UBS.

It is necessary to link strategies that promote health services by riverside dwellers, enabling the continuity of health care for these populations.


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FINANCIAL SUPPORT Amazonas State Research Support Foundation.

Article originally published in Portuguese (

Translated by: Luana de Jesus Lemos

How to cite this article / Como citar este artigo: Guimarães AF, Barbosa VLM, Silva MP, Portugal JKA, Reis MHS, Gama ASM. Access to health services for riverside residents in a municipality in Amazonas State, Brazil. Rev Pan Amaz Saude. 2020;11:e202000178. Doi:

Received: January 13, 2019; Accepted: December 06, 2019

Correspondence / Correspondência: Abel Santiago Muri Gama. Estrada Coari Mamiá, 305. Bairro: Espírito Santo. CEP: 69460-000 - Coari, Amazonas, Brasil - Tel.: +55 (97) 98121-9295. E-mail:


Guimarães AF, Barbosa VLM, Silva MP, Portugal JKA and Reis MHS contributed to data acquisition, review and interpretation of results. Gama ASM contributed to the design of the paper, acquisition, analysis and interpretation of data, writing, and critical review of the content.


The authors declare that there are no conflicts of interest regarding this research.

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